Briefing Document on Medication use and Falls This document is intended as a briefing document and is not to be regarded as a document offering definitive legal advice in relation to the subject matter. Publication Date: June 2013 Version 1 To enable this information to achieve its full potential, it has been agreed by the Irish Medication Safety Network that the copyright for this publication shall be waived. We would ask, however, if any of the content of the Briefing Document is shared or reproduced, the source of the information is appropriately acknowledged, and a link to the document on our website www.imsn.ie is provided.
Table of Contents Definitions..3 Introduction... 3 Causes of Falls..4 Discussion Resources on Medication and Falls.... 4 Conclusion. 7 References 8 Prepared by Niamh O Hanlon, Chief II Pharmacist, St. Vincent s University Hospital, Dublin 4 On behalf of, and in consultation with the Irish Medication Safety Network. Reviewed by Claire Browne, Senior Pharmacist, Pharmacy Dept, St. Vincent s Private Hospital, Dublin; Dr. Stephen Byrne, Senior Lecturer, School of Pharmacy, University College Cork; About the IMSN The Irish Medication Safety Network (IMSN) is an independent group of pharmacists and other specialists working in the acute sector, whose principal aim is to improve patient safety with regard to the use of medicines through collaboration, shared learning and action. The following document is based on best practice as of June 2013. Website: www.imsn.ie Email: enquiries@imsn.ie Publication Date: June 2013 Page 2 of 8
Definitions A fall has been defined as: a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force. 1 ADL Activities of Daily Living FALLSAFE A Royal College of Physicians (UK) delivered quality improvement project (2010-2012) which focused on prevention and management of falls in clinical hospital wards in Southern England. 2,3 NICE National Institute for Health and Care Excellence (UK) START Screening Tool to Alert doctors to Right Treatment. 4 STOPP Screening Tool of Older People s Prescriptions. 4 Introduction The consequences of falling, particularly for older people, are a serious public health problem and a cause of ill-health and death. As people get older, the risk of falling, and of injury or harm from falls, increases. One in three older people fall every year and two-thirds of them fall again within six months. As Ireland s population ages, the burden of falls and related injuries could double over the next 25 years. Falls and harm from falls can be predicted and prevented. 5 Older people experience more concurrent illnesses, are prescribed more medications and suffer more adverse drug events than younger people. Many drugs predispose older people to adverse events such as falls and cognitive impairment, thus increasing morbidity and health resource utilisation. 4 The literature and hospital-based exploration of fall-related injury suggest that the following groups of patients are most at risk for injury if they sustain a fall: Individuals who are greater than or equal to ( ) 85 years old or frail due to a clinical condition Patients with bone conditions, including osteoporosis, a previous fracture, prolonged steroid use, or metastatic bone cancer Patients with bleeding disorders, either through use of anticoagulants or underlying clinical conditions Post-surgical patients, especially patients who have had a recent lower limb amputation or recent, major abdominal or thoracic surgery. 6 The IMSN briefing document focuses on falls and the extrinsic risk factor medication. Irish hospitals, in general, have a falls policy, however specific individual hospital guidance on falls risk and medication is inconsistent. 7 Publication Date: June 2013 Page 3 of 8
Causes of Falls Risk factors for falls are multifactorial. Any hospital s falls prevention programme policy should address the intrinsic, extrinsic and environmental hazards identified as risk factors in falling (Table 1) Table 1: Risk Factors for Falls and Fractures adapted from HSE 2008 Strategy 5 & Lamis et al. (2012) 8 Intrinsic: Muscle weakness History of falls Gait and balance deficits Visual deficit Arthritis Depression Cognitive impairment Age greater than 80 years Urinary incontinence Orthostatic or postprandial hypotension Dizziness Fear of falling Limited activity Environmental: Environmental hazards Home hazards Extrinsic: Use of assistive devices Impaired activities of daily living (ADL) High level of activity (community setting) Medications (see below) Medication: Polypharmacy ( 5 medicines daily) 9 Drugs which affect Central Nervous System 8 o Anticonvulsants o Antidepressants o Antihistamines (sedating) o Antiparkinsonians o Antipsychotics o Anxiolytics, Sedatives and Hypnotics o Opioid analgesics Class 1a antiarrhythmics Antihypertensives Diuretics Laxatives Discussion Resources on Medication and Falls There is controversy regarding the strength of evidence for medicines associated with falls. Differences in study methods, setting, power and definitions of a fall have made it difficult to draw firm conclusions regarding the impact of various medicines on falls risk. 10, 11 Additionally, there are challenges in terms of competing clinical priorities when considering discontinuing falls risk medicines. Despite the points above, medication review is considered a worthwhile intervention as part of a multifactorial falls prevention policy and is advocated by many patient safety organisations. A number of publications are available which may form useful resources when specifically looking at a medication and falls risk, for a hospital falls risk policy. Publication Date: June 2013 Page 4 of 8
FALLSAFE The Royal College of Physicians (UK) led on a quality safety initiative - the Fallsafe project which focused on prevention and management of falls in clinical hospital wards in Southern England from 2010-2012. 2 From the Fallsafe project results, the College recommends that all patients should have their drug burden reviewed with respect to its propensity to cause falls. The medication history should establish the reason the drug was prescribed, when it was commenced, whether it is effective and what its side effects have been. An attempt should be made to reduce the number and dosage of medications, and ensure they are appropriate and not causing undue side effects with respect to falls risk. The Fallsafe project recommends the following: Avoidance of prescriptions for night sedation. Medication review for medication that can increase the risk of falls they provide a list of medications divided into drugs which affect the brain, and drugs which affect the heart and circulation. John Radcliffe Hospital, Oxford, the key lead in the FallSafe project, published guidance on Medication and Falls in hospitals, subsequently approved by the British Geriatrics Society. 12 Medications are classified into different classes of risk of falling, using a traffic light system (see below). For the most updated list, see http://www.bgs.org.uk/campaigns/fallsafe/falls_drug_guide.pdf Low risk of falls The Royal College of Physicians (UK) provide a comprehensive online falls prevention resource 13, and advocate a care bundle for all patients to reduce risk of falls. It defines tasks which should be undertaken at admission to identify those patients at increased risk, and to ensure the environment around the patient minimizes risk of falling. Additional care bundles are provided for those over age of 65, and for patients who have suffered a fall. See reference list for website addresses for falls prevention resources, and specific FallSafe care 3, 12, 13 bundles. Publication Date: June 2013 Page 5 of 8
HSE The 2008 publication Strategy to Prevent Falls and Fractures in Ireland s Ageing Population 5 states that a review of medication(s) and dose(s) should be undertaken as part of multifactorial assessment. Suggested interventions relating to medicines include: Withdrawal or minimisation of psychoactive medications. Withdrawal or minimisation of other culprit medications. JOINT COMMISSION INTERNATIONAL (JCI) PATIENT SAFETY GOAL Joint Commission International (JCI) is an American based accrediting body for hospitals, used globally, and nationally by 17 private hospitals and one public hospital in Ireland. Reducing the risk of patient harm resulting from falls is one of six international patient safety goals of JCI. 14 The JCI note that falls account for a significant proportion of injuries in hospitalized patients. In the context of the population it serves, the services it provides, and its facilities, the organisation should evaluate its patients risk for falls and take action to reduce the risk of falling and to reduce the risk of injury should a fall occur. The evaluation could include fall history, medications and alcohol consumption review, gait and balance screening, and walking aids used by the patient. The organization is required to establish a fall-risk reduction program based on appropriate policies and/or procedures. The program should monitor both the intended and unintended consequences of measures taken to reduce falls. STOPP/START Front line staff working in both hospitals, and in the community, can use the STOPP and START tools reliably during their everyday practice to identify potentially inappropriate medications, and potential errors of omission in older patients. 15 Publication Date: June 2013 Page 6 of 8
Conclusion Inpatient falls often result in injury, prolonged hospital stays, higher medical costs and increased mortality rates. 8 There are many risk factors for falling and for harm resulting from falling. Medications are considered an extrinsic risk for falls. 5 Certain medication classes as outlined in table 1, in addition to the number of concomitant medications taken by a patient, are risk factors for falling. 8 The NICE 2013 Falls guidance re-iterates the importance of medication review, as part of a multifactorial approach to falls prevention. 16 In practice, even where medications that can cause risk of falls are identified, in many cases (e.g.antihypertensives) there are challenges changing or stopping them as the clinical benefit may outweigh the falls risk to the patient. The IMSN recommends that, in collaboration with a pharmacist, a specific section on medications and falls risk, referencing useful tools for front line staff to identify risk to patients, should form part of a hospital s falls risk policy. Publication Date: June 2013 Page 7 of 8
References 1. Feder, G. Cryer, C. Donovan S. & Carter Y (2000) Guidelines for the Prevention of Falls in People over 65. BMJ 321:1007-1011 2. Dowaski A & Byrne L (2011) The FallSafe Project Published by the British Geriatric Society Available at: http://www.bgs.org.uk/index.php?option=com_content&view=article&id=1545:fallsafe&catid=47:fal lsandbones&itemid=307 3. Royal College of Physicians (2011) Fallsafe Care Bundles Available at: http://www.bgs.org.uk/campaigns/fallsafe/cstd_fallsafe_carebundle.pdf 4. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. (2008) STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther Feb;46(2):72-83. 5. Department of Health and Children,the Health Service Executive and the National Council on Ageing and Older People (2008) Strategy to Prevent Falls and Fractures in Ireland s Ageing Population. Available at: http://www.hse.ie/eng/services/publications/services/olderpeople/strategy_to_prevent_falls_and _Fractures_in_Ireland%e2%80%99s_Ageing_Population_-_Full_report.pdf 6. Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D, Rita S. How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA: Institute for Healthcare Improvement; 2012. Available at: www.ihi.org. 7. Irish Medication Safety Network (2012) Survey on Falls policy, medication section and pharmacist involvement: Response from 15 hospitals (public and private) unpublished 8. Lamis, R. Kramer, J. Hale L. Zackula, R. & Berg, G. (2012) Fall risk associated with inpatient medications Am J Health-Syst Pharm 69; 1888-94 9. Onder G, Petrovic M, Tangiisuran B et al. Development and validation of a score to assess risk of adverse drug reactions among in-hospital patients 65 years or older: the Gerontonet ADR risk score. Arch Int Med. 2010; 170: 1142-1148 10. Hartikainen S, Lonnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci 2007 Oct;62(10):1172-81. 11. Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009 Nov 23;169(21):1952-60 12. John Radcliffe Hospital, Oxford (2011) Medicines and Falls in Hospitals Guidance Sheet Available at www.bgs.org.uk/campaigns/fallsafe/falls_drug_guide.pdf 13. Royal College of Physicians (2010) Falls Prevention Resources Available at http://www.rcplondon.ac.uk/resources/falls-prevention-resources 14. Joint Commission International Accreditation Standards for Hospitals, 4 th edition 2011 International Patient Safety Goals IPSG.6 The organization develops an approach to reduce the risk of patient harm resulting from falls. 15. Ryan C, O Mahony D & Byrne S (2009) Application of STOPP and START Criteria: Interrater Reliability Among Pharmacists Ann Pharmacother 43; 1239-44 16. NICE Clinical guideline 161 June 2013 Falls: assessment of prevention of falls in older people. Available at http://www.nice.org.uk/nicemedia/live/14181/64166/64166.pdf Publication Date: June 2013 Page 8 of 8